Medical Care最新文献

{"title":"Hospital Ownership Type Correlated With Investments in Nursing Services: Evidence From Illinois.","authors":"K Jane Muir, Kathy S Sliwinski, Daniela Golinelli, Matthew D McHugh, Karen B Lasater","doi":"10.1097/MLR.0000000000002148","DOIUrl":"https://doi.org/10.1097/MLR.0000000000002148","url":null,"abstract":"<p><strong>Background: </strong>The association between hospital ownership type and patient care quality has garnered increased public attention.</p><p><strong>Objectives: </strong>To describe differences in investments in nursing services, care quality and safety, and nurse job outcomes among for-profit and not-for-profit hospitals in Illinois.</p><p><strong>Research design: </strong>Cross-sectional, descriptive case study of hospital nursing services, patient care quality and safety outcomes, and nurse job outcomes in 113 hospitals in Illinois in 2021. Three datasets were linked through a common identifier: RN4CAST-IL nurse survey, National Academy for State Health Policy (NASHP) cost data, American Hospital Association (AHA) Annual Hospital Survey.</p><p><strong>Measures: </strong>Nursing services included patient-to-nurse staffing ratios and the quality of the nurse work environment. Nurse job outcomes included burnout, job dissatisfaction, and intent to leave.</p><p><strong>Results: </strong>For-profits had statistically significantly lower investments in nursing services, worse nurse job outcomes, and poorer patient care quality and safety outcomes relative to not-for-profit hospitals, despite having no statistically significant differences in operating margins. For-profit hospitals had poorer nurse work environments (mean score 2.5 vs. 2.9, P<.001) and worse staffing ratios (6.8 vs. 4.7 patients per nurse, P<0.01), higher percentages of nurses intending to leave their employer (36.2% vs. 22.8%, P<.01), higher job dissatisfaction (37.9% vs. 23.4%, P<.01), higher burnout (63.8% vs. 46.2%, P<.05), and worse quality and safety (e.g., poor patient safety grades 53.6% vs. 33.8%, P<.01).</p><p><strong>Conclusions: </strong>Investments in nursing services as well as quality and safety of patient care in for-profit hospitals are worse than in not-for-profit hospitals, despite having no significant differences in operating margins.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 8","pages":"594-599"},"PeriodicalIF":2.8,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144784640","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of Maryland's 2015 Nurse Practitioner Full Scope of Practice Law on Statewide Rates of Outpatient Potentially Harmful Medication Prescribing to Older Adults.","authors":"Jessica Lipori, Joshua Thorpe","doi":"10.1097/MLR.0000000000002163","DOIUrl":"10.1097/MLR.0000000000002163","url":null,"abstract":"<p><strong>Background: </strong>Since 2010, there has been an increase in Full Scope of Practice (FSP) laws allowing nurse practitioners (NPs) to practice independently. We aimed to utilize synthetic control models to examine the impact of a 2015 NP FSP laws on outpatient potentially harmful medication (PHM) prescribing to older adults (65 years and above) in Maryland.</p><p><strong>Methods: </strong>We utilized Medicare Public Use Files to measure statewide rates of outpatient PHM prescribing to older adults with Part D from fiscal year 2013-2019. An interrupted time series analysis was performed, and geographic and health access covariates were used to create synthetic control models. Placebo tests were used to test differences in PHM prescribing after the policy change.</p><p><strong>Results: </strong>The interrupted time series analysis was not significant. Maryland's synthetic control model chose a weighted average of New Jersey, Delaware, and Massachusetts. There was no significant difference in PHM prescribing after the passage of Maryland's FSP law compared with synthetic control.</p><p><strong>Discussion: </strong>We found that Maryland's FSP law did not impact statewide rates of PHM prescribing. State-wide prescribing trends should be considered in states debating changes in nurse practitioner scope of practice.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"588-593"},"PeriodicalIF":2.8,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144225875","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effects of Expanding Medicaid Dental Coverage on General Health Status of Low-Income Adults.","authors":"George L Wehby, Wei Lyu, Julie Reynolds, Steven M Levy","doi":"10.1097/MLR.0000000000002162","DOIUrl":"10.1097/MLR.0000000000002162","url":null,"abstract":"<p><strong>Background: </strong>Oral health is considered a key component of general health. However, causal evidence examining the effects of dental coverage on general health is sparse.</p><p><strong>Objectives: </strong>To examine the effects of the Affordable Care Act (ACA) Medicaid expansions with extensive dental benefits versus less generous dental benefits on the general health status of individuals with low income.</p><p><strong>Research design: </strong>A difference-in-differences design comparing states that expanded Medicaid eligibility in 2014 by whether they offered extensive or less generous dental benefits.</p><p><strong>Subjects: </strong>Adults aged 18-64 years below 138% of the federal poverty level who participated in the 2011-2022 Behavioral Risk Factor Surveillance System surveys.</p><p><strong>Outcome measures: </strong>Self-rated general health status and number of days not in good physical health or good mental health in the past 30 days.</p><p><strong>Results: </strong>The likelihood of fair/poor rated health status declined with extensive dental benefits, including by 2.3 (95% CI: -3.90 to -0.69) percentage-points when aggregating 2014-2022, with declines first observed in 2015 and almost all years after. There were no statistically significant effects on days not in good physical or mental health when aggregating 2014-2022. There were fewer mentally unhealthy days with extensive dental benefits by 0.93 days in 2019 and 2021 (95% CI: -1.80 to -0.06 and -1.70 to -0.15, respectively).</p><p><strong>Conclusion: </strong>The findings suggest that extensive dental coverage improves self-rated general health status among low-income adults. There is suggestive evidence of improved mental health in 2 but not all years and no discernable effect on days not in good physical health.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"606-613"},"PeriodicalIF":2.8,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143971429","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Award-Winning Student Manuscripts From the American Public Health Association 2023.","authors":"Linda D Green, Katherine S Virgo, Julie M Zito","doi":"10.1097/MLR.0000000000002166","DOIUrl":"https://doi.org/10.1097/MLR.0000000000002166","url":null,"abstract":"","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 8","pages":"563-564"},"PeriodicalIF":2.8,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144742672","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effects of Cognitive Behavioral Therapy on Chronic Uncontrolled Diabetes: A Randomized Clinical Trial in a Shared Primary Care Setting.","authors":"Ryan Bellacov, Yvonne Novasio","doi":"10.1097/MLR.0000000000002170","DOIUrl":"10.1097/MLR.0000000000002170","url":null,"abstract":"<p><strong>Background: </strong>In the context of escalating diabetes prevalence worldwide, this study investigates the efficacy of integrating cognitive behavioral therapy (CBT) within primary care visits for managing uncontrolled diabetes.</p><p><strong>Design: </strong>The randomized clinical trial in an integrated health care clinic in Oregon involved 72 adults aged 20-89 with uncontrolled diabetes. Participants were enrolled and randomly assigned to 2 groups: one receiving both cognitive behavioral health (n=36) and the other receiving traditional primary care (n=36).</p><p><strong>Results: </strong>The study primarily measured clinical improvements in hemoglobin A1C levels for a year. Results indicated significant improvements in the cognitive behavioral health group compared with the traditional care group at various intervals up to 51 weeks, with notable enhancements in hemoglobin A1C and secondary outcomes of patient satisfaction scores. During the 36 th and 51st weeks, the shared visit group demonstrated significantly lower hemoglobin A1c levels (36 wk: 9.22±0.2 vs. 10.02±0.2, P <0.001; 51 wk: 9.22±0.1 vs. 10.91±0.2, P <0.001), indicating improved long-term glycemic control.</p><p><strong>Conclusions: </strong>Combining cognitive behavioral health with primary care visits significantly outperformed traditional care in improving clinical outcomes and patient satisfaction among adults with uncontrolled diabetes. The percentage of participants with clinically meaningful improvement in 36 weeks was 22.2% in the CBT versus 0.0% in the traditional primary care visit group. The positive outcomes suggest that integrated cognitive behavioral therapy can effectively contribute to diabetes management strategies, highlighting the importance of innovative approaches in addressing the diabetes epidemic.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"539-544"},"PeriodicalIF":2.8,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144225874","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Change Over Time in Hospital Care for Medicaid Beneficiaries: Analysis of Hospitalizations From 2016-2019.","authors":"Jacqueline Xu, Jeffrey D Hodis, Kary Calderon, Paul J Chung, Robert S Nocon","doi":"10.1097/MLR.0000000000002124","DOIUrl":"10.1097/MLR.0000000000002124","url":null,"abstract":"<p><strong>Background: </strong>Historically, access to high-quality care has been a central challenge for Medicaid programs. Prior single-year analyses demonstrated that Medicaid beneficiaries account for disproportionately high patient volumes at low-quality hospitals. Given major Medicaid shifts including expansion and increased managed care, we examined recent trends in low-quality hospital use for Medicaid beneficiaries.</p><p><strong>Methods: </strong>Using Healthcare Cost and Utilization Project State Inpatient Databases, we compiled adult hospital discharges from 15 states in years 2016-2019 (N=32,788,446). Hospital quality was assessed with the Agency for Healthcare Research and Quality (AHRQ) Composite Inpatient Quality Indicator, reflecting risk-adjusted mortality for prevalent conditions. We constructed a logistic regression modeling odds of discharge from a low-quality hospital (bottom 20 th percentile by year), with payer-year interactions and covariates for patient demographics (sex, age, race/ethnicity, income), comorbidities, state, and hospitalization type.</p><p><strong>Results: </strong>Overall, patients with Medicaid [adjusted odds ratio (aOR)=1.11, P <0.01] or Medicare (aOR=1.03, P <0.01) were more likely to be hospitalized in low-quality hospitals, compared with private insurance (reference). The likelihood of admission to low-quality hospitals over time varied by payer. Patients insured by Medicaid were 2% less likely to be admitted to low-quality hospitals each additional year (aOR=0.98, P <0.01). Medicare-insured patients did not show significant changes longitudinally, and privately insured patients were 3% more likely to be admitted to low-quality hospitals each year (aOR=1.03, P <0.01).</p><p><strong>Conclusions: </strong>This is one of the first studies examining associations between payer and inpatient care quality over time, critical for our rapidly changing payment environment. Although Medicaid-insured patients remain more likely to be discharged from low-quality hospitals as compared with other payers, we find promising recent trends of improving hospital quality over time for Medicaid beneficiaries.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"573-578"},"PeriodicalIF":2.8,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143008131","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving Patient Experience With Provider Communication: Systematic Review of Interventions, Implementation Strategies, and Their Effectiveness.","authors":"Tiago S Jesus, Manrui Zhang, Dongwook Lee, Brocha Z Stern, Jan Struhar, Allen W Heinemann, Neil Jordan, Anne Deutsch","doi":"10.1097/MLR.0000000000002158","DOIUrl":"10.1097/MLR.0000000000002158","url":null,"abstract":"<p><strong>Background: </strong>Provider communication with patients may be improved through training, shadow coaching, and other in-service interventions. We aim to synthesize these interventions, implementation strategies, and their impact on the patient experience.</p><p><strong>Methods: </strong>A systematic review of contemporary evidence (2015-2023). Six scientific databases, specialty journals, and snowballing searches identified training, shadow coaching, and other in-service interventions for improving provider communication with patients, evaluated by standardized patient experience measures. Studies without inferential statistics were excluded. Two independent reviewers assessed the studies' eligibility and methodological quality and mapped the implementation strategies against a widely used taxonomy of 73 strategies.</p><p><strong>Results: </strong>Of 1237 papers screened, 14 were included: 10 controlled studies (5 randomized) and 4 prepost. Nine studies were on communication skills training and 3 on shadow coaching; all but one of these used a train-the-trainer implementation strategy. Eight studies (controlled n=4) used 5.5-8 hours of communication training and showed significant improvements in selected experience outcomes. Brief (45 min) communication training showed no significant results. Two controlled studies showed that shadow coaching and recoaching achieve short-term improvements but eroded without booster sessions. The use of transparent surgeon masks improved selected communication outcomes, but periodic reminders sent to clinicians on communication etiquette did not.</p><p><strong>Discussion: </strong>In-service communication training (≥5.5 h) or shadow (re-)coaching by trained peers can improve patients' experience with provider-patient communication. To implement such interventions, organizations need to identify and train trainers/coaches, intentionally support the program, monitor effectiveness, and add boosters as needed. Brief communication etiquette training or simple reminders did not improve the patients' experiences with provider-patient communication.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"545-554"},"PeriodicalIF":2.8,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144001238","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is a Distressed Birth Associated With Physical and Mental Health Problems as an Adult?: Evidence From Panel Data.","authors":"Michael T French, Karoline Mortensen","doi":"10.1097/MLR.0000000000002156","DOIUrl":"10.1097/MLR.0000000000002156","url":null,"abstract":"<p><strong>Background: </strong>A considerable amount of research has examined the short-term health outcomes associated with distressed births. Most studies have focused on the survival of the newborn, health complications, and medical care utilization. Comparatively little research has considered the longer-term physical and mental health outcomes of distressed births that survive into adulthood.</p><p><strong>Objectives: </strong>The primary objective is to determine whether 3 common types of distressed births-low birth weight (LBW), preterm delivery, neonatal intensive care unit (NICU) admission-are significantly related to physical (ie, self-reported overall health status, number of chronic health conditions) and mental (ie, number of mental health disorders) health among young and middle-aged adults.</p><p><strong>Subjects: </strong>Respondents to Waves IV (2008-2009; N=15,701) and V (2016-2018; N=12,300) of the National Longitudinal Survey of Adolescent to Adult Health (Add Health) provide the data for our research.</p><p><strong>Research design: </strong>Our empirical approach estimates numerous multivariate regression models for Waves IV and V separately, and mixed-effects models for both waves combined. Each subgroup (LBW, preterm delivery, and NICU admission) was analyzed separately in comparison to those without a distressed birth.</p><p><strong>Results: </strong>All 3 distressed birth measures are negatively and significantly ( P <0.05) associated with physical and mental health status in adulthood.</p><p><strong>Conclusions: </strong>The primary implication is that clinicians, public health advocates, and policy makers at all levels of government can use these findings to secure additional resources for the prevention of future distressed births. Prevention initiatives can include teenage family planning, prenatal checkups and related care, and incentives for healthy behaviors during pregnancy.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"624-636"},"PeriodicalIF":2.8,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144003408","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Text Message Outreach Intervention to Increase Health Insurance Enrollment for Self-Pay Patients.","authors":"Yan Lu, Kevin J Craten, Caitlin T Thompson, Robert Scroggins, Jeff Claassen, Joshua Manning, Rohit P Ojha","doi":"10.1097/MLR.0000000000002157","DOIUrl":"https://doi.org/10.1097/MLR.0000000000002157","url":null,"abstract":"<p><strong>Background: </strong>Self-pay patients may be unaware of their eligibility for health insurance coverage through government or hospital-based medical assistance programs.</p><p><strong>Objectives: </strong>We aimed to evaluate the effect of behaviorally informed text message outreach on insurance enrollment among self-pay patients discharged from the emergency department (ED) at a safety-net hospital.</p><p><strong>Research design: </strong>We emulated a single-arm trial with a historical comparison. Our eligible population included self-pay ED patients aged 18-64 years who were discharged between October 31 and November 24, 2022 (outreach group) or between April 1 and July 31, 2022 (historical comparison). We used entropy balancing weights to adjust for baseline characteristics and estimated overall and race/ethnicity-specific risk ratios (RR), risk differences (RD), and 95% confidence limits (CL) for the effect of the text outreach on insurance enrollment.</p><p><strong>Results: </strong>The study population comprised 748 patients in the intervention and 6199 in the comparison group. The median age was 36 years (interquartile range=28-47), 58% were male, and 65% were racial/ethnic minorities. Overall outreach effect on any coverage enrollment (RR=1.4, 95% CL: 1.2, 1.6; RD=7.1%, 95% CL: 3.7%, 10%) was larger than the effect on hospital-based medical assistance program and Medicaid enrollment (RR=1.2, 95% CL: 1.0, 1.4; RD=2.7%, 95% CL: -0.24%, 5.7%). The latter effect was largest in the Hispanic population.</p><p><strong>Conclusions: </strong>Our results suggest behaviorally informed text outreach increases insurance enrollment among self-pay patients discharged from the ED at a safety-net hospital and may complement broader strategies to increase health insurance enrollment. Future studies should compare different text message strategies.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 8","pages":"600-605"},"PeriodicalIF":2.8,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144742671","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Health Equity and Hospital Markets: Differences in the Association of Market Concentration and Quality of Care by Patient Race/Ethnicity and Payer.","authors":"Alexander C Adia, Charleen Hsuan, Hector P Rodriguez","doi":"10.1097/MLR.0000000000002123","DOIUrl":"10.1097/MLR.0000000000002123","url":null,"abstract":"<p><strong>Background: </strong>As hospital markets become increasingly consolidated, whether regulators should account for consolidation's impacts on health equity has become a key policy question. We assess the association of hospital market concentration with quality of care and examine differences by patient race/ethnicity and payer.</p><p><strong>Methods: </strong>We analyzed linked 2017 American Hospital Association Annual Survey and Healthcare Cost and Utilization Project State Inpatient Data from 14 US states. Market concentration was measured using the Herfindahl-Hirschman Index (HHI) at the county level, and quality was assessed using the Prevention Quality Indicators (PQI). We assessed the relationship of HHI, patient race/ethnicity, and payer with having any PQI admission, controlling for patient and hospital characteristics. We used interaction terms for race-HHI and payer-HHI to assess differential associations of concentration by race/ethnicity and payer using linear probability models.</p><p><strong>Results: </strong>In adjusted analyses, minoritized racial/ethnic group status and having a noncommercial primary payer were associated with a higher probability of having a PQI admission. Differences between Hispanic adults and White adults decreased in more competitive markets but increased for Asian/Pacific Islander adults versus White adults. Differences in the probability of a PQI admission between adults covered by Medicaid and self-pay/no-pay adults versus commercially insured adults increased, while differences for adults covered by Medicare decreased.</p><p><strong>Conclusions: </strong>Hospital market concentration may have heterogeneous effects on the quality of care by patient race/ethnicity and payer. Because market concentration may impact equity, regulators should consider accounting for health equity impacts in merger reviews.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"565-572"},"PeriodicalIF":2.8,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12233174/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143657629","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}